Page 13 - 2021_Gray West_Benefits_Guide_Final
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Quick Contact Details:
Your Health Phone: 888-650-4047
Website: anthem.com
Anthem Login to your Anthem
account at anthem.com
Health Insurance Download Mobile Health in the
App Store or Google Play
We’re pleased to offer two medical plan options administered through Anthem, a provider of
exceptional healthcare services. Once enrolled, you can visit anthem.com to access claims
payments, physician directories, ID cards and inquire about eligibility. Dependent
coverage can be obtained until the end of the month in which a child turns 26.
CALENDAR YEAR BENEFITS HIGH DEDUCTIBLE PPO 2250 PLAN
Deductible (Single/Family) $3,000/$6,000 $2,250/ $6,750
Out-of-Pocket Maximum (Single/Family) $3,000/$6,000 $4,500/$9,000
Physician/Specialist Office Services Copay 0%/0% $20/$40
Inpatient Facility Coinsurance 0% 20%
Outpatient Surgery Facility Coinsurance 0% 20%
Emergency Room Services Copay/Coinsurance $0/$0 $75/0%
Urgent Care Services Copay/Coinsurance $0/$0 $40/0%
Lifetime Maximum Unlimited Unlimited
RX TIER All TIERS TIER 1 TIER 2 TIER 3 TIER 4
Rx - Retail Pharmacy 0% $10 $30 $60 25%
Rx - Mail Order Pharmacy 0% $20 $60 $120 25%
In-network Preventive Services are covered at 100% on both plans.
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